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Will Be Be Processed When Submitted ProperlyGorrlpletea. ow <br /> Applications <br /> lications APPLICATION <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> [.Cs ENVIRONMENTAL HEALTH PERMIT <br /> WATER 4pALiTY x" lication is <br /> CA <br /> les and regulations of the San Joa uin o a -T\isherebymadtothe San e ,loaquinLocal4iAalthDistrict2and the rules <br /> l Health District.oconstructand/orinstall the work herein describe <br /> (COMPLETE IN TRIPLICATE) d.Thlsapp <br /> ApplicationOrdinance No.166 + <br /> made in compliance with San Joa uln County City/Town <br /> Exact Site Address Phone <br /> Owner's Name " CityMIND <br /> AddressF ,ra. License# —7 Business Phone <br /> Contractor's Name Emergenoy..Phone <br /> No <br /> Contractor's Address <br /> Q <br /> is Certificate of Workman's Compensation lnsuran eon Fel❑With IRECOND{TION�STRUCTION❑ ` <br /> TYPE OF WORK (CHECK): NEW WELL. <br /> ❑ - DEEPEN <br /> WELL ABANDONMENT � OTHER ❑ PUMP INSTALLATION® PUMP REPAIR© � <br /> WELL .CHLORINATION C3W ( <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank,l.I Cesspool/Seepage Pit <br /> Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line—private Domestic Well <br /> I <br /> INTENDED USE TYPE OF WELL CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> 9 DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> G ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: . <br /> ❑ GEOPHYSICALyr,] j ` ti•- <br /> Contractor H.P. <br /> PUMP INSTALLATION. AType of Pump <br /> IF❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done Approximate Depth <br /> PUMP REPAIR: I Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> 4 <br /> - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> g.., <br /> ch manner as to become subject to workman's compensation e work for this <br /> Home owner or licensed agent's signature certifies the following, I certify that in the performance of the w rk for which this perms <br /> is issued, i shall not employ,any person in I certify that in the performance o �S <br /> to persons subject to workman's compensation Laws= f California." <br /> Contractor's hiring orsub-contracting signature certifies the following: <br /> permit is issued, i shall employ p �y <br /> Grout inspection grouting and a tin I insp c o <br /> I for a n prior to r ,rr <br /> I fir Date: <br /> Ti I . <br /> Signed i r (Draw Plot PI on R erse Side) <br /> FOR DEP TMENT USE ONLY <br /> �� �v�'��®` pate <br /> i <br /> PRASEr J <br /> Application Accepted By k <br /> sIII e <br /> Additional Comments: Final Ins coon 3 <br /> � D_,J�',e <br /> Phase 11 Grout Inspection inspection By /� <br /> inspection By Date January 31 ❑ y Jul 1 &Received By July 31 <br /> I ❑ PER SITE ❑ EACH ❑ January 1 &Received By REMIT <br /> Fee Is Due: C1'ANNUALLY El UNIT $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT- <br /> BASE EXPLANATION DATE DATE <br /> FEE <br /> -LESS <br /> PRORATION _ is .. - <br /> PLUS 4 - <br /> PENALTY - c '- <br /> OTHER ti <br /> OTHER <br /> e IS3 aS —Z5 Delivered <br /> Issuance Date MaiYed <br /> ' Permit No. - CA 95201 <br /> Received by <br /> Date _ - Receipt No. ,. - 1B01 E.HAZELTON AVE.,P.O.8a9 2009 STOCKTON, <br /> ENVIRONMENTAL HEALTH PERMITlSERV1GES <br /> APPLICANT—RETURN ALL COPIES TO: <br />